Download ER SOAP

ER SOAP
Patient’s Name: Mr. M.
Location: DRMC ED
Date & Time: 6/7/12, 14:17
Subjective:
Chief Complaint: 76 y/o male presents to Dubois Regional Medical Center ED stating, “For the
past three days I have been having a lot of upper abdominal pain and a lot of "rifting".
History of Present Illness: The presenting abdominal pain symptoms radiate in the epigastric
area, right and left hypochondriac regions, and to the left shoulder. Pertinent positives: nausea,
vomiting, alternating chills and diaphoresis, chest pains, eructation, and swollen, painful
abdomen. The quality is described as constant, achy, sharp, shooting, and stabbing. Modifying
factors: The symptoms are alleviated by nothing, the symptoms are aggravated by food, touching
the area, and lying flat on back. Severity of pain: At its worst the pain was severe in the
emergency department, 8/10, the pain is unchanged since onset three days ago. The patient has
been recently seen by a physician, the patient's primary care provider, two days ago with similar
presenting complaints. Patient's symptoms have worsened and persisted after given Prilosec
without relief. Arrived with spouse. Care prior to arrival: none. Activity prior to arrival: none.
Patient denies any recent travel, changes in diet or exercise habits, starting any other medications
besides Prilosec, or exposure to anyone with a current illness. Myocardial infarction appeared
negative at triage by lack of EKG abnormalities; cardiac enzymes pending at this time. Patient
has HTN, hypercholesterolemia, and diabetes. Patient denies syncope or LOC, paroxysmal
nocturnal dyspnea, edema, diarrhea, colicky pain, hematuria, hematemesis, flank pain, RLQ
pain, or irritable bowel disease. History is negative for diverticulitis, esophageal strictures,
heartburn, ulcers, gastritis, gastroenteritis, or ascites.
Past Medical History:
Allergies: Penicillin & Keflex – developed rash, Claritin – developed upset stomach.
Comorbidities: Diabetes – NIDDM for 20 years; Hypertension for 15 years;
Hypercholesterolemia for 15 years.
Immunizations: Flu vaccine August 2011, Zostavax 2008, Pneumovax 2001, Tetanus 2001.
Hospitalizations, Injuries, Surgeries: Skin Graft and Hand Surgery 2001; Hernia repair 2005.
Trauma: Broken hand 2001.
Oral Medications:
1. Simvastatin Oral 40 mg q.d.
2. Glyburide Oral 2.5 mg b.i.d.
3. Lisinopril Oral 10 mg q.d.
4. Omeprazole Oral 40 mg q.d.
5. 600 mg Ibuprofen q.d. as needed
6. No OTC supplements or other medications taken
Reproductive History: One daughter who is 45 y/o. No sexual dysfunction stated.
Youth Illnesses: None
No history of renal disease, pulmonary disease, clotting disorders, or cancer. Patient denies any
recent infection within last six months. No previous abdominal complaints or similar pain.
Social History:
Family: The patient lives with wife, one grown daughter lives in area, no siblings, parents and
grandparents are deceased.
Lifestyle: Active around the house. Does not exercise or follow any special diet. No recent travel
in last six months. Patient hobbies include photography and horseback riding.
Abuses: Denies smoking, drinking, or drug use.
Marital status: Married 47 years, has monogamous relationship, still sexually active.
Employment: Retired from post office. Financially stable, middle socioeconomic class.
Support System: Wife, daughter and son-in-law live in the area. Wife and daughter present in ED
with patient.
Family History:
There is no family history of renal disease, clotting disorders, appendicitis, cholecystitis,
hepatitis, pancreatitis, diverticulitis, gastritis, irritable bowel disease, or GERD. Daughter has no
known history of severe illness or disease. Family history shows genetic predisposition for
diabetes, cardiovascular disease, hypertension, pulmonary disease, and cancer in both maternal
and paternal parents and grandparents. Father died from lymphoma at 69 y/o. Mother had
diabetes, HTN, and died from AMI at 80 y/o. Paternal grandfather died from lung cancer at 79
y/o. Paternal grandmother died from cerebral hemorrhage at 78 y/o. Maternal grandfather died
from AMI at 85 y/o. Maternal grandmother died from metastasized breast cancer at 75 y/o.
Review of Systems:
General: Low energy level, fatigued, uncomfortable and in pain for past three days. Patient
recognizes alternating chills and diaphoresis since pain onset. Denies history of depression or
anxiety.
HEENT:
Head: Patient denies any swelling, redness, rashes, recent headaches, lymphadenopathy
or current diaphoresis.
Eyes: No change in vision, diplopia or eye pain.
Ears: No noted hearing loss, no tinnitus.
Nose: No epistaxis or nasal drainage.
Throat: Consistent eructation and difficulty swallowing for past three days.
Neck: Patient denies any masses, rash, erythema, or lymphadenopathy.
Pulmonary: Patient denies any cough, wheezing, hemoptysis, tachypnea, or SOB. No history of
pneumonia or TB exposure, asthma, or COPD.
Chest/CV: Patient denies any palpitations. Patient has HTN for past 15 years, controlled with
medication. Left sided chest pain radiating from epigastric and left hypochondriac regions; pain
worse when lying flat on back.
Vascular/Heme: No history of gangrene, DVT, aneurysm, blood or clotting disorders, or
anemia. Denies increased bleeding, bruising, or lymphadenopathy.
G.I.: Decreased appetite that started three days ago. Patient complains of abdominal pain and
distention, nausea, vomiting; worse after eating. Patient denies any diarrhea. Patient has
hypercholesterolemia for past 15 years, controlled with medication. Prior GI history
unremarkable without any history of appendicitis, diverticulitis, IBD, gastritis, or cholecystitis.
G.U.: Afebrile, no hematuria. No dysuria, incontinence, or nocturia.
GYN: No history of sexually transmitted disease. Patient denies any penile discharge, pain,
discomfort, rashes, or lesions.
MS/Extremities: Patient denies any edema, cyanosis, muscle aches, pain or swollen joints. No
deformities or current joint or back pain.
Rheumatic: No history of gout, rheumatic arthritis, or lupus.
Endocrine: Has diabetes mellitus type II for past 20 years, on medication for but still
uncontrolled. No history of thyroid disease. Denies tremors, polyuria, polyphagia, or polydipsia.
Patient complains of heat and cold fluctuations.
Skin/Dermatological: No new rashes, pruritus, or ecchymosis. Denies any irregular moles or
changes in hair distribution. Patient denies having been bitten by or removal of any ticks.
Neurological: There is no history of seizures, stroke, syncope, or memory changes.
Objective:
14:25 B/P: 138/84, Pulse: 80, RR 20, T 98.7, Pulse Ox 98% RA, Pain 8/10, Wt. 192, Ht. 5’10”
General: Alert and oriented X3, in obvious pain, uncomfortable. Well developed, laying down
in bed. Well groomed and acting appropriately for age. BMI 27.5 - patient is overweight.
Head: No apparent masses, scars, or lacerations. Normocephalic, atraumatic. No tenderness
upon palpation.
Eyes: Lids and lashes normal. Conjunctiva and sclera are non-icteric and not injected. Cornea
within normal limits. Periorbital areas without swelling, redness, or edema. Pupils equal, round
and reactive to light, EOM intact, visual fields respond to confrontation. No nystagmus or ptosis.
Ears: Tympanic membranes are normal and external auditory canals are clear. No tenderness on
palpation. Hearing equal responses bilaterally with scratch test.
Nose: Septum not deviated. No nasal discharge, obstruction, or polyps. Nares patent. No
tenderness on palpation.
Throat: Oropharynx without redness, swelling, masses, exudates, or evidence of obstruction.
Uvula midline. Normal gag reflex. Moist mucous membranes.
Neck: Supple, trachea midline. No JVD, thyroidmegaly, masses, or lymphadenopathy
appreciated. Full ROM without vertebral tenderness, no meningismus. Carotids without bruits.
Pulmonary: No increased work of breathing, no retractions or nasal flaring. No rashes, lesions,
or scars. Tenderness over left and right hypochondriac region upon palpation. No consolidation
appreciated. Normal tactile fremitus and diaphragmatic excursion at 5 cm. Lungs have equal
breath sounds bilaterally, clear to auscultation and percussion. No rales, rhonchi or wheezes
appreciated.
Chest/CV: Normal chest wall appearance and motion. PMI not visible at left 5th ICS/MCL. No
lifts, heaves, rashes, scars, thrills or edema appreciated. Tenderness over left hypochondriac
region upon palpation. Regular rate and rhythm on EKG, actual rate is 80 bpm, normal S1 and
S2, no S3 or S4, no murmur, no gallops, no JVD. No pulse deficits.
Vascular/Heme: Brisk capillary refill < 3 seconds. No active bleeding, bruises,
lymphadenopathy, peripheral edema or cyanosis appreciated. Pulses equally bilaterally.
Pulses
Carotid
Brachial
Radial
Dorsalis P
Post Tibial
R
2+
2+
2+
2+
2+
L
2+
2+
2+
2+
2+
GI: No deformities, striae, rashes, scars, or abnormal masses appreciated. Abdominal distention
present. Bowel sounds: normal, in all quadrants, no bruits. Liver span 7cm by percussion.
Spleen, bladder, and kidney margins normal without enlargement. McBurney’s point is
nontender. Severe abdominal tenderness, in the right and left hypochondriac and epigastric
regions. Predominant guarding with radiating pains to left shoulder.
G.U. No dysuria or oliguria. Normal UA color and clarity.
GYN: No penile discharge, lesions, rashes, or pain. FOBT negative, no hemorrhoid(s) or masses
appreciated.
MS/Extremity: Skin cool and dry. No clubbing, cyanosis, scoliosis, kyphosis, or lordosis
appreciated. No CVA tenderness on palpation. No spinal deformities or pain upon palpation.
Full active and passive range of motion. Motor strength 5/5 in all extremities.
Rheumatic: No arthritis, Heberden or Bouchard nodes appreciated. No tenderness to palpation
over joints or with AROM.
Endocrine: No goiter or exophthalmos appreciated. Thyroid normal upon palpation.
Skin: Skin warm and dry, normal color without rashes, lesions, or ecchymosis. Good capillary
refill and skin turgor. No tenderness upon palpation of extremities.
Neuro: Awake and alert, oriented to person, place, time, and situation. Cranial nerves I-XII
grossly intact. Sensory grossly intact. Cerebellar exam normal. Normal gait. Normal DTR’s 2+,
no Babinski.
14:31 Glasgow Coma Score: Total 15
Eye response: spontaneous 4, Verbal response: oriented 5, Motor response: obeys commands 6
Diagnostics:
14:20 ECG:
Interpretation: Rate is 80 bpm. Rhythm is regular, Normal Sinus Rhythm with no ectopy.
QRS Axis is Normal. PR interval is normal. QRS interval is normal. T waves are Normal.
No ST changes noted. Clinical impression: No evidence of ischemia.
14:42 Fingerstick Blood Sugar: Interpretation: Abnormal: 216
14:42 CBC w/ Diff:
Interpretation: WBC 13.48, Hgb 16.4; Hct 47.6; Plt Count 158, RBC 5.25, MCV 90.7,
MCH 31.2, MCHC 34.5, MPV 11.3
14:42 CMP:
Interpretation: BUN 12.7, Creatinine 0.95, Total protein: 8.0, Albumin 3.9, Globulin 4.1,
Calcium 9.1, Bili Total 0.7, Na 135, Potassium 4.2, Chloride 100, CO2 25.6, AlkPhos 63,
AST 9, ALT 20
14:42 Troponin-I: Interpretation: Normal: Troponin-I <0.015
14:45 Amylase Level: Interpretation: Normal: Amylase Lvl 69
14:45 Lipase Level: Interpretation: Abnormal: Lipase Lvl 438
15:08 Auto Diff: Interpretation: Abnormal: Neut Abs Auto 10.38
15:23 Gallbladder US: Interpretation: Normal: GB, no wall thickening, no fluid. CBD normal
diameter. Will CT abdomen to evaluate aorta and remaining abdominal viscera.
15:39 GFR: Interpretation: Normal: Non AfnAmer GFR >60
16:00 CT: Shows pancreatitis, early necrosis. No hydronephrosis, no stones, no aneurysm or
dissection.
Assessment:
1. Acute Pancreatitis r/i on CT showing early necrosis, abdominal exam with tenderness upon
palpation of right and left hypochrondriac and epigastric regions, abdominal distention, and
elevated pancreatic lipase level
2. Myocardial infarction r/o on EKG and normal troponin level
3. CHF r/o with negative BNP, negative history (edema, abnormal heart sounds), negative
CXR, and normal EKG
4. Cholecystitis r/o on US
5. Choledocholithiasis r/o on US
6. Hepatitis r/o on CT, LFT labs
7. Gastritis r/o on CT
8. Renal colic r/o on CT and negative history
9. Abdominal aortic aneurysm r/o on CT
10. Peritonitis r/o on CT and abdominal exam without diffuse pain
11. Peptic ulcer disease r/o without relief on Prilosec
Plan:
Patient requests transfer to Geissinger. Have discussed with internal medicine, Dr. Hergen, who
accepts the patient. He will go by ground and be evaluated in the ED there prior to admission.
Pain scale upon departure was 3.
Treatment for patient w/ pancreatitis:
1. Hospitalization
2. Monitoring vitals pulse ox, blood pressure, respiratory rate, EKG
3. Gastroenterologist and endocrinologist consult and referral
4. NPO for biopsy on necrotic area
5. Dilaudid PRN
(After biopsy)
6. IV fluids to maintain BP
7. Low-fat diet
8. NSAIDs
9. Possible pancreatic enzyme replacement therapy (Creon/pancrelipase)
10. Possible surgery to remove necrotic tissue (necrosectomy) or Whipple’s procedure
11. Close follow-up and monitoring with gastroenterologist, endocrinologist, and primary care
physician. This would include weekly, monthly, and/or yearly lab testing, enzyme
monitoring, US and CT scans.
12. Patient education for pancreatitis includes alcohol avoidance, low fat diet and/or TPN
feeding, pain management, fluid hydration, infection prevention, necrosectomy preparation
and lifestyle management with enzyme supplementation. Additional education should be
provided on diabetes management, hypercholesterolemia management, and HTN/heart
comorbidities management.
Signature: Candy Hull, PA-S
Date: 6/7/12, 20:00